Assessment should guide intervention.
Before beginning treatment, we assess clients to target the most effective modalities and involve clients and family members in their selection. For example, one person we worked with was a painter before his stroke, so we incorporated drawing into his intervention program. In assessing patients, we also consider limb apraxia and handedness, which could affect writing, drawing and gesturing. If a person can't functionally model a gesture,he or she will certainly never try using it outside of treatment. For example,gesturing the words "writing" or "pencil" may be difficult for some people who struggle with fine-motor movements. When a patient can use only one hand, we sometimes emphasize using one-handed gestures rather than two-handed gestures.We also suggest assessing clients' semantic abilities—using, for example, the Pyramids and Palm Trees and subtests of the Psycholinguistic Assessment of Language Processing in Aphasia—because intervention combining both semantic and multimodal treatment may best help some clients.

Treatment should aid integration of verbal and nonverbal representations.
Instead of instructing clients in, say, using gesture for a number of concepts before moving on to instruction in writing or drawing, clinicians instruct clients to integrate multiple modalities for a single concept. For example, when providing instruction on the word "cat," a clinician would encourage the person with aphasia to practice gesturing, drawing, writing and saying the word before providing instruction in another concept. Including spoken expression in this instruction increases the likelihood that clients will use other modalities when words fail. It also helps assure clients and families that spoken expression is not forgotten.

Treatment should support comprehension.
Many patients with aphasia benefit from augmented input or the simultaneous presentation of other modalities with spoken expression. Augmented input can help them understand instructions and perform treatment tasks. For example, we found that using photographs, written keywords and gestures helped a client understand directions and effectively perform a role-playing activity.

Treatment should integrate existing evidence.
Whenever possible, we incorporate evidence about how best to instruct people to learn particular modalities. For example, instruction in written expression may follow steps similar to those in Pélagie Beeson and colleagues' Copy and Recall Treatment protocol for providing instruction in written expression. The CART protocol provides structured modeling and opportunities for imitation.

Manipulating the intensity (frequency and length) of intervention sessions could amplify treatment. The rehabilitation field is increasingly noting the value of intense treatment protocols involving significant repetition of target behaviors. Providing intensive multimodality treatment (for example, one to three hours daily for two weeks) may lead to rapid acquisition and maintenance of strategies.

Increasing treatment intensity could allow more time to be spent on other activities key to boosting functioning. For example, after completing the more traditional modeling and imitation, people with aphasia may benefit from practicing communication modalities in role-play situations to ease their use of different modalities in real-life situations.

Providing awareness training can boost self-awareness and self-monitoring in some people with neurological disorders. In addition to multimodal treatment, some people with aphasia may benefit from additional instruction to increase their awareness of communication breakdowns and their success at repairing these breakdowns. For example, the clinician may work with them on predicting and recognizing such breakdowns, and on how to address such difficulties.